This paper discusses the political circumstances which help explain why the insanitary living conditions of such a large section of India’s urban population have been ignored, and contrasts these with the circumstances which explain successful sanitary reform in Britain in the second half of the 19th century. In India, there is little middle class pressure for sanitary reform, in part because of the ability of the middle classes to monopolize what basic urban services the state provides, in part because modern medicine and civil engineering have lowered the health risks that they might face from the sanitation-related diseases that lower income groups suffer. In addition, the ’threat from below’ including organized trade union pressure was more influential in mid 19th century Britain than in India today. The paper ends by reflecting on what factors might change this.